Prior Authorization: Provider Perspectives Part 2

In the previous newsletter, we summarized how providers feel about the complexity of the prior authorization process.? We will continue here with more concrete details.??

A recent physician survey [7] suggests that provider organizations may be spending more than a third of their effort following the prior authorization process.? In the survey, almost all physicians (89%) agree that prior authorization hurts patient outcomes; nearly all (94%) report that there is a delay in care owing to the prior authorization; over a quarter say that the patients abandon treatment, and a third suggest that the prior authorization leads to a significant adverse patient event.? A third of physicians also felt that the prior authorization process is often seeking information that is clinically not valid and most of them (86%) reported that the prior authorization process may actually end up increasing the use of healthcare resources by adding unnecessary office visits and ineffective treatments [8]. Providers find the prior authorization process to be tedious and demeaning to their training and skill set.?Dr. Jack Resneck reflects “These are hours that we could be spending actually taking care of patients as opposed to fighting all these appeals” [9].?

The prior authorization process is becoming less opaque, but it is not completely transparent. What kind of information is a payor looking for?? Healthcare coverage decisions are influenced by a complex combination of factors, including medical necessity, cost-effectiveness, medical guidelines, policy terms, and negotiation with healthcare providers. These can vary among insurers and even within different plans offered by a given insurer. Standardizing and implementing such a transparent model may be still a work in progress [10]. Currently, insurers may not disclose the basis of their decision process to maintain a competitive edge, protect the source of their information, or avoid other operational challenges. In such scenarios, providers may be at a loss to provide adequate information causing denials and delays. In other cases, the request is denied when an approach to a condition is justified and evidence-based but the payors may not have known about it or are yet to recognize the treatment [11].??

While there is a unanimous consensus among the providers that the prior authorization process is broken, there is a growing sentiment among the physicians who have thought deeply about our healthcare that prior authorization is merely a symptom of what has gone wrong. These physicians express fundamental concerns that our underlying models of healthcare delivery may be flawed. For example, radiologist Dr. Vivian Lee author of the book “The Long Fix” argues [12] that the fee-for-service healthcare model has shifted our focus from caring to “doing”: Doing unnecessary procedures and tests splurging on our valuable healthcare resources.? Dr. Atul Gawande, who is a surgeon by profession and teaches at Harvard Medical School suggests [13] that by considering unlikely causes of symptoms, the physicians are increasingly overprescribing treatment plans that insurers will approve.? He also adds that sometimes the providers overprescribe so as not to have any regrets of not trying all possible options. I felt that by providing a convenient narrative connecting justifiable tests and procedures for associated symptoms, the prior authorization system has given legitimacy to an approach to caring that is hemorrhaged with prescriptions and constipated of cures!??

How to provide adequate and timely care for the patients while not being exhausted defending their care choices? It is a provider’s nightmarish conundrum! The premise that there can be a fair and effortless system approval for effective treatment plans that can be justified is turning out to be a wild goose chase!? Many frustrated providers and patients are trying to change the fabric of the current system by appealing to the regulators (e.g., [14]) and publicly shaming the payors [15]. While still others think any superficial changes will not be effective without changing the underlying model of healthcare delivery.?

Join us for future episodes delving into payer and patient perspectives on prior authorization. Thank you for reading!?

References:

1. Forbes Health Advisor?
2. Addressing commercial health plan abuses ensure fair coverage patients providers?
3. ICD codes?
4. DSM codes?
5. CPT codes
6. Clinical coder - Wikipedia?
7. Physician Prior Authorization Survey??
8. Prior authorization increases use of health care resources, physicians say??
9. What doctors wish patients knew about prior authorization?
10. Use of Cost-Effectiveness Analysis in Health-Care Resource Allocation Decision-Making?
11. Advocating for Patients with Inflammatory Bowel Disease.?
12. Why We Pay More And Get Less From U.S. Healthcare : NPR?
13. ?Overkill?
14. ?CMA sponsors bill to reform the broken prior authorization process (cmadocs.org)?
15. Doctors, patients try to shame insurers online to reverse authorization denials?

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